Fertility History and Investigations for Both Partners

Both Partners:

How long have you been trying to conceive:

Please describe infertility problem:

Please describe investigations performed and results of these:

Please describe infertility treatments (when, what, and detailed results):

What treatment are you planning to undergo at the Cape Fertility Clinic?

Do you require donor sperm from the Cape Cryo bank?

We require copies of the following tests:

Female Partner:

Blood tests:

HIV I & II antibodies

RPR/VDRL/TPHA (Syphilis)

Hepatitis B surface antigen

Hepatitis C antibodies

Rubella IgG (immunity)

Day 3 FSH

TSH

Prolactin

Transvaginal ultrasound scan of the pelvis

HSG (hysterosalpingogram) or hysteroscopy or saline infusion sonogram

Male Partner:

Blood tests:

HIV I & II antibodies

RPR/VDRL/TPHA (Syphilis)

Hepatitis B surface antigen

Hepatitis C antibodies

Semen analysis

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